Oncological, surgical, and cosmetic outcomes of endoscopic versus conventional nipple-sparing mastectomy: meta-analysis

Abstract

Background: Endoscopic nipple-sparing mastectomy has been developed to improve the cosmetic outcomes of conventional nipple-sparing mastectomy. This meta-analysis compares surgical, quality of life and oncological outcomes of endoscopic nipple-sparing mastectomy versus conventional nipple-sparing mastectomy.

Methods: PubMed and Embase were systematically reviewed to identify literature relevant to endoscopic nipple-sparing mastectomy and conventional nipple-sparing mastectomy literature published through to August 2023. The risk of bias was assessed using the Newcastle-Ottawa Scale, and proportional and pairwise random-effects meta-analysis was performed. Surgical (operative time, duration of hospital stay, blood loss, necrosis, overall complications), quality of life (cosmesis, pain, nipple-areolar complex sensitivity) and oncological outcomes (margin positivity, recurrence, metastasis and breast cancer-specific mortality rate) were evaluated.

Results: Of 1286 articles retrieved, 51 endoscopic nipple-sparing mastectomy studies and 12 conventional nipple-sparing mastectomy reviews were analysed; 10 non-randomized comparative studies (656 patients) were included in the pairwise analysis and 36 studies (comparative and single-group cohort studies; 2612 patients) in the proportional meta-analysis. Results showed no differences in oncological outcomes (mean follow-up of up to 52 months), comparable overall (OR = 0.49; P = 0.100) and necrotic complications (OR = 0.45; P = 0.150), and improved cosmetic satisfaction (OR = 1.88; P = 0.020). Comparing only single-incision endoscopic nipple-sparing mastectomy to conventional nipple-sparing mastectomy significantly reduced postoperative necrosis (OR = 0.19; P = 0.008). The proportional meta-analysis produced oncological and surgical outcome rates comparable to or lower than conventional nipple-sparing mastectomy rates. However, longer operative time (weighted mean difference = 43.08 min; P < 0.00001) and duration of hospital stay (weighted mean difference = 0.72 days; P = 0.0007) were observed.

Conclusion: Endoscopic nipple-sparing mastectomy does not affect oncological outcomes in up to 52 months mean follow-up when compared with conventional nipple-sparing mastectomy and provides better cosmetic satisfaction, with a reduced risk of necrosis after single-incision endoscopic nipple-sparing mastectomy. As such, endoscopic nipple-sparing mastectomy may become a viable breast surgery option.

Fig. 1

PRISMA flow chart of endoscopic nipple-sparing mastectomy (E-NSM) literature search

Fig. 2

PRISMA flow chart of conventional nipple-sparing mastectomy (C-NSM) systematic review literature search

Fig. 3

a Local recurrence in endoscopic nipple-sparing mastectomy (E-NSM) versus conventional nipple-sparing mastectomy (C-NSM); b distant metastasis in E-NSM versus C-NSM; c margin positivity in E-NSM versus C-NSM; d breast cancer-specific mortality rate in E-NSM versus C-NSM. Note: Lai et al. did not provide statistical comparison of patient demographics between E-NSM and C-NSM; Wang et al. reported greater BMI and significant differences in tumour stage in the C-NSM cohort; Lai et al. reported more patients with substantial breast ptosis in the E-NSM group. M–H, Mantel–Haenszel.

Fig. 4

a Operative time in endoscopic nipple-sparing mastectomy (E-NSM) versus conventional nipple-sparing mastectomy (C-NSM); b duration of hospital stay in E-NSM versus C-NSM. Note: Qiu et al. and Lai et al. utilized flap or flap + implant-based immediate breast reconstruction (IBR); Lai et al. used tissue expander, flap + implant-, flap- or implant-based IBR or no IBR; and Wang et al. used implant-based IBR or tissue expanders. All other publications used implant-based IBR. *Zhang et al. reported operative time separately for patients undergoing nipple sparing mastectomy + immediate breast reconstruction (NSM + IBR) with axillary lymph node dissection (ALND) versus NSM + IBR with sentinel lymph node biopsy (SLNB). Asterisk denotes SLNB cohort. IV, indipendent variable.

Fig. 5

a Overall complications in endoscopic nipple-sparing mastectomy (E-NSM) versus conventional nipple-sparing mastectomy (C-NSM); b necrosis in E-NSM versus C-NSM. Note: Lai et al. did not provide statistical comparison of patient demographics between E-NSM and C-NSM; Wang et al. reported greater BMI and significant differences in tumour stage in the C-NSM cohort; Lai et al. reported more patients with substantial breast ptosis in the E-NSM group. M–H, Mantel–Haenszel.

Fig. 6

a Estimated incidence of overall complications for endoscopic nipple-sparing mastectomy (E-NSM); b estimated incidence of necrosis for E-NSM.

Fig. 7

Necrosis in single-incision endoscopic nipple-sparing mastectomy (E-NSM) versus conventional nipple-sparing mastectomy (C-NSM)

Fig. 8

Percentage of patients satisfied with cosmetic results in endoscopic nipple-sparing mastectomy (E-NSM) versus conventional nipple-sparing mastectomy (C-NSM)